Provider Demographics
NPI:1154360154
Name:DAVIDSON, WENDY LEE (NP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:LEE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:2100 STATHAM BLVD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033
Practice Address - Country:US
Practice Address - Phone:805-330-8685
Practice Address - Fax:805-367-5250
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP8632363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100430OtherGROUP MEDI-CAL
CARN305841Medicaid
CA1902846306OtherGROUP NPI
CAW18762OtherGROUP MEDICARE
CAWNP8632EMedicare PIN
CARN305841Medicaid
CAWNP8632DMedicare PIN